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number of organisms which succeed in invading the

atmosphere.A great deal requires to be done to improve anti-infective

measures and to test their relative value in actual hospitalconditions. It is deplorable that so many opportunitieshave been missed of testing the value of new design inexperimental units in our existing hospitals when irre-vocable decisions involving large sums of public moneyhave now to be taken in building the new ones. In our

judgment, however, the time is not propitious for anoverall recommendation to abolish showering, and it is

irresponsible for this suggestion to have been made atthis time on the evidence available.

J. H. BOWIER. W. TONKIN

J. S. ROBSON.Royal Infirmary,Edinburgh, 3.

SCREENING FOR CANCER OF THE CERVIX

J. ELIZABETH MACGREGORMARY E. FRASEREVELYN M. F. MANN.

Department ofObstetrics and Gynæcology,University of Aberdeen.

SIR,-We were most interested in the article by Dr.Jones and Dr. Metcalfe Brown (March 6) and the subse-quent letters from Dr. Jennings (March 20) and Dr. Govanand Dr. Peacock (March 27), but more evidence is neces-sary before conclusions can be drawn.

Progression from carcinoma-in-situ to clinical presentationof cervical cancer is thought to take 17-20 years. In theAberdeen region the average age of over 200 patients withpreinvasive carcinoma of the cervix was found to be 36 years,that of 80 showing microscopic invasive changes was 44 years,and that of over 500 clinical cases was 53 years. Of 27,000women who had had smears taken (1958-1963), while only4% of the cytologically detected cases showed microscopicinvasive changes in the under-30 age-group, 50% showed thesechanges in the over-50 group. These figures indicate a pro-gression from carcinoma-in-situ in the early 30s, through aphase of microscopic invasion to clinical presentation in the 50s.There are about 40,000 women at risk (married women

between the ages of 25 and 60 years) in the city of Aberdeen.If the detection-rate of presymptomatic cervical cancer at anyone time is 10 per 1000 and progression to clinical cancer cantake up to 20 years, then one would expect about 20 cases to

present clinically each year. This corresponds closely with theknown annual incidence in Aberdeen over the past 20 years.

In agreement with Dr. Jones and Dr. Metcalfe Brown, wehave found that when we screen the general population inAberdeen, the attendance-rate for screening varies with thesocioeconomic group of the women who are invited to attend.The detection-rate is higher in the lowest social group, who arethe most difficult to persuade to attend for screening.

In the city of Aberdeen 6500 healthy women, whose age,parity, and social class are representative of the general popula-tion, have been screened by us in their own doctors’ surgeries.Our detection-rate of presymptomatic lesions was 7 per 1000,which we submit is too low because we are not yet obtainingsmears from all the patients in the groups at highest risk.These findings indicate to us that our detection-rate is

realistic and that all our cytologically detected and histo-logically confirmed cases would, if left untreated, progressto clinical cancers.

J. ELIZABETH MACGREGOR

PSYCHIATRY AS A MEDICAL SPECIALTY

MARTIN ROTH.

Department of Psychological Medicine,Royal Victoria Infirmary and

University of Newcastle upon Tyne,Newcastle upon Tyne, 1.

SIR,-In his article (March 13), Professor Fish suggeststhat the high incidence of schizophrenia reported by socialpsychiatrists among individuals living in relative isolationin city slums and among members of the lowest socio-economic groups is illusory, and " that this belief derivesfrom the misdiagnosis of schizophrenia ..."

The two states are associated, however, and there have beenfindings similar to those reported from Chicago 1 in a number ofAmerican and British cities; a clear social-class gradient in theprevalence of schizophrenia has also been found on both sidesof the Atlantic. If error in diagnosis yields such consistentresults with a number of psychiatric investigators in differentcountries, one could wish there were more of it. The uniform-ity and reliability of psychiatric diagnosis would be likely toshow a gratifying improvement.

Social psychiatrists have been not quite as simple as Pro-fessor Fish implies when he says that they have assumed that" the manifestations of mental illness can all be explained bysocial dislocation ". A great deal of well-designed and pains-taking work has been done in an attempt to sift cause and effect.Thus a number of inquiries have tried to ascertain how far theapparent association between schizophrenia and low socio-economic status could be explained in terms of the socialdecline that schizophrenia tends to produce, as distinct fromthe contribution that might be made to the causation of theillness by adverse social circumstances. Most recent studies 2 3

appear to suggest that the association is largely due to the driftof schizophrenics down the social scale, although a small contri-bution to causation by an unfavourable social environment isnot excluded by these findings.

Professor Fish may, of course, be correct in his viewthat the prevalence of schizophrenia in individuals of lowsocioeconomic status is wholly illusory, and we hope thathe will, in due course, substantiate the interesting sug-gestions he has advanced. Meanwhile, many of us will haveto draw what conclusions we can from the availableevidence.

HEROIN AND COCAINE ADDICTION

SIR,-In his timely article (April 10) Dr. Bewley drawsattention to several disturbing aspects of the problem ofheroin and cocaine addiction in this country; the official

figures which he cites show the striking increase amongthe young up to 1963-an increase which, from my ownexperience, has continued ever since. How much thesituation has changed over the past few years is evidentfrom a comparison with findings in this country obtainedby an American sociologist 4 who remarked, in 1962, onthe relatively high proportion of professional addicts, therarity of addiction among the young, and the relative lackof evidence of an " addict subculture " and of the use ofaddicts’ slang. These statements do not apply today.

I can confirm Dr. Bewley’s comment that the presentincrease of heroin and cocaine addiction follows case-to-casespread.5 Our hypothetical average heroin-addicted patient wasintroduced to the drug by friends or acquaintances, or at clubs,almost always by addicts who were (as they wrongly call it"

registered " with a doctor, and who managed to acquire asurplus; after buying the drugs for weeks or months, such ayoungster then felt unable any longer to afford the averageprice of El per grain of heroin or cocaine, and decided tobecome " registered

" himself-ofteii starting to sell his ownsurplus soon afterwards. In my experience, the official figuresclearly underestimate the number of individuals who at anyone time take heroin regularly,5 since the early " experi-menters

" often become addicted fairly rapidly. The findingthat a heroin addict must be regarded as a focus of infectionmust be kept in mind when considering the wisdom of theregular prescribing of heroin to addicts by general practitioners.It must be very difficult in a busy general practice to determine1. Paris, R. E. L., Dunham, H. W. Mental Disorders in Urban Areas.

Chicago, 1939.2. Goldberg, E. M., Morrison, S. L. Brit. J. Psychiat. 1963, 109, 785.3. Hare, E. H. J. ment. Sci. 1956, 102, 349.4. Schur, E. M. Narcotic Addiction in Britain and America. London, 1962.5. Glatt, M. M. Brit. med. J. 1964, i, 1116.

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exactly the quantity needed by an addict who may thus getmore than he needs. Moreover, it might be less difficult towithdraw relatively early heroin abusers and help them tostay off the drug than long-standing addicts who have beenprescribed the drug regularly for some time-both becausephysical dependency may be less strong at an earlier phase,and because early abusers have not yet become attached tothe way of life and the " subculture " of long-standing addicts.On the other hand, genuine addicts should have the opportunityto obtain the drug legally, possibly at centralised clinics, thusreducing the risk of their being thrown into the arms of large-scale marketeers. The rapidly changing pattern clearly pointsto the need for some committee to keep the situation continuallyunder review, as suggested by Dr. Bewley.At present, few hospitals are keen to admit more than a small

number of heroin and cocaine addicts for long-term therapy.But such an aggregation of addicts at one place may createcertain problems. The Synanon’ organisation, in America, isapparently quite successful,6 but there they seem to deal withhighly motivated addicts, whereas heroin and cocaine addictsadmitted for treatment to hospitals in this country usually lackmotivation.One difficulty may arise in the use of marihuana-which

seems to be relatively widespread among such youngsters.From Dr. Bewley’s table I, 12 out of 13 heroin and cocaineaddicts aged less than twenty-five years had taken marihuanain the past, as against 5 out of 14 of addicts over twenty-fiveOnly a small minority of youngsters taking’marihuana go onto taking heroin, thus illustrating the importance of personalityfactors in addition to availability of the drug-yet practicallyall our young heroin and cocaine addicts had originally startedoff by smoking

" reefers ", and were still doing so by the timethey came to hospital. They usually feel strongly that there isno harm in smoking reefers, rightly pointing out that marihuanais not " addictive " in the sense of producing physical depen-dence, but forgetting that such behaviour, in face of legalprohibition and the risk of imprisonment, certainly points toa state of psychological dependence. From our experience withsmall units of such addicts, attempts to smuggle in marihuanamust be expected from time to time.

Other problems may arise from the often undisciplinedattitude of these youngsters, with their insistence on beingallowed to act however they wish, who may thereby createdifficulties with other patients and with the nursing staff.From the doctor’s point of view group psychotherapysessions with such addicts certainly seem to be valuableand useful; but wherever groups of addicts are to beestablished the provision of an adequate nursing staffis an absolute need.

M. M. GLATT.St. Bernard’s Hospital,Southall, Middlesex.

STANDARDISATION OF BLOOD-PRESSURE

MEASUREMENT

W. ANTONY BALL.

SIR,-Each year the serial and comparative recordingof blood-pressure increases in importance. Variousmodes of therapy are evaluated by such records. Thearticle by Dr. Rose (March 27) bears witness to the

variability of such records and their possible unreliability.The systolic reading is accepted as the cessation of sound;

but the diastolic reading may be the change in loudness of thesound, the cessation of sound, or some other point. Thesemust all be different readings, but the actual point chosen isnever mentioned in clinical records and very rarely in publishedreports.At present it is impossible to insist that one method should

be chosen throughout the world to determine the diastolic

reading, but it should be possible to insist that all publishedreports and clinical records indicate the method used.

6. Volkman, R. 1st International Congress Social Psychiatry. London, 1964.

PROBLEMS OF PROFESSIONAL WOMEN

BARBARA LITTLEWOODLaw Society

JOAN O. JOSHUARoyal College of Veterinary

SurgeonsNADINE BEDDINGTON

Royal Institute ofBritish Architects

JEAN LAWRIEHon. secretary of committee.

ANNE BOLTONChairman,

Medical Women’s Federation

JOYCE BISHOPAssociation of Headmistresses

SHEILA MARS-JONESBar Council

MARGARET FOXInstitute of Chartered Accountants

in England and Wales

SIR,-An interprofessional working party has been setup to study the careers of qualified women with particularreference to the so-called wastage.The working party will study different aspects of the profes-

sional life of women-particularly those which are common toall the professions. At the moment we are considering theposition of the married woman in relation to taxation, and arepreparing a memorandum on expenses allowable for incometax, housekeeper allowance, and surtax.We believe that the cost to the professional woman of replac-

ing herself in her home by the employment of domestic helpmakes it uneconomic, in many cases, for her to go out to work,and we are therefore seeking ways of alleviating the position.The working party invites inquiries and opinions which

should be addressed to the Honorary Secretary, Inter-professional Working Party, c/o the Medical Women’sFederation, Tavistock House North, Tavistock Square,London, W.C.1.

GASTRIN

W. M. CAPPERT. J. BUTLERK. G. BUCKLER.

SiR,—It is a great pleasure to see the name of LesterDragstedt among your contributors (April 10). His fameas a gastric physiologist is world-wide, and we should liketo take this opportunity of acknowledging the immensevalue of his contributions to the etiology and treatment ofduodenal ulcer.We cannot agree, however, " that gastric ulcers are usually

caused by a hypersecretion of gastric juice of humoral or gastrinorigin ... " Secretion studies in gastric ulcer usually revealnormal secretion or hyposecretion, often with a marked alkalinephase at night. We are not aware of any conclusive evidencethat prolonged endogenous secretion of gastrin in man producesgastric ulceration. Where gastrin activity is known to be

excessive-i.e., in the Zollinger-Ellison syndrome-gastrichypersecretion is manifest, but the ulceration is usually duodenalor jejunal in situation.

In addition to the lack of correlation between gastric hyper-secretion and gastric ulcer, we feel that the association of gastricstasis and gastric ulcer is suspect, for the following reasons:

1. In pyloric stenosis, with undoubted stasis, the presenceof a classical gastric ulcer is uncommon.

2. Studies of gastric emptying times in over 80 patientswith gastric ulcer by one of us (K. G. B.) showed a rangevery similar to that found in normal controls and in duodenalulcer patients, in contradistinction to the findings ofOberhelman.2 2

3. Although a simple gastric ulcer can be cured bypyloroplasty alone, this operation does not reduce the time ofgastric emptying. Furthermore, when vagotomy is added topyloroplasty, emptying time is greatly prolonged,’ but theulcer will heal.

4. A chronic gastric ulcer may persist despite adequatedrainage by low gastroenterostomy.We believe therefore that the evidence for relating

gastric ulcer to hypersecretion and to stasis is inadequate.

1. Buckler, K. G. Paper to British Society of Gastroenterology, Nov. 13,1964.

2. Oberhelman, H. A. The Physiology and Treatment of Peptic Ulcer.Chicago, 1959.